Michel de Groulard, Godfrey Sealy, Brader Brathwaite

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1Michel de Groulard, Godfrey Sealy, Brader BrathwaitePauline A. Russell-Brown, Hans-Ulrich WagnerCheryl O’Neil, Caroline Allen, Emmanuel JosephHomosexual Aspects of the HIV/AIDS Epidemic in the Caribbean: A Public Health Challenge for Prevention and ControlLet me first acknowledge the Caribbean Epidemiology Center collaborating with the French Cooperation and its Member Countries, and particularly the small communities of very stigmatized MSM in the small Caribbean islands.A special mention to the field investigator of this study, Godfrey Sealy, sitting in this room, without who none of this would ever had happened.

2Reported AIDS Cases in CAREC Member Countries, 1982 - 19985001,0001,5002,0002,50019821983198419851986198719881989199019911992199319941995199619971998YearsNumber of CasesThe first case of AIDS in the Region was recorded in Jamaica in The Region has the highest incidence of reported AIDS cases in the Americas and world wide is second only to Africa in terms of adult HIV prevalence rate (2.1%)

3Gender Distribution of Reported Adult AIDS Cases in CMCs 1982-1998Men play major role in the transmission of HIVMale-Female Sex ratio = 2:157% of heterosexual transmissionTransmission through heterosexual contact is reported as the main route of transmission (64%),17% of all reported AIDS cases have not been related to any of the above routes of transmission and are reported as “unknown” or “no risk factor”.More than 80% of the cases reported in this unknown group, are male cases.

4Categories of Transmission in Reported Adult Male AIDS Cases through Sexual Contacts 1992 - 1998In cases reported in men, heterosexual transmission is 60%,Therefore 40% of male cases are not reported to be transmitted through heterosexual contact.The level of HIV prevalence in MSM is not known but there are strong indications, from health care practitioners reporting a large number of young gay men dying from AIDS, that it is high

5Male Risk Category by Year in Trinidad & TobagoIn the example case of Trinidad and Tobago, it appears clearly that as the proportion of cases reported as homo and bisexual transmission is decreasing, the proportion of “unspecified” increases.

6Homosexuality in the CaribbeanCriminal offence in most countriesHigh level of stigmatisation and discriminationRejected by families and communitiesSubject to physical violenceIndividuals and practices driven undergroundSexual orientation not fully acceptedIndividuals remain “in the closet” or adopt socially acceptable heterosexual visible lifestyleThe practice of sex between men is a criminal offence in most countries, highly stigmatized, particularly by religious groups, and perceived as delinquent behavior. The society as a whole strongly rejects homosexuals.Recent developments of violence in Jamaica and of criminalization of homosexuality in Dominica indicate the level of fear and passion that the issue emotes in the region.From a public health promotion perspective, a climate of fear and discrimination is counter productive, driving individuals and practices underground and making both invisible.Because of the social and religious pressure, most gay men do not fully accept their sexual orientation, with very little family or peer support.In such a stigmatized environment, men who participate in same sex relationships either remain “in the closet” or, to gain social acceptance, may get married and attempt to conform to the heterosexual norm.They live a double life, which not only place them at risk, but also increase the risk of HIV infection for their female partners and for any resulting children.

7MSM & HIV in the CaribbeanHigh stigma of HIV positive sero statusDouble stigma for HIV+ and MSMLimited communication with MSM and within the openly gay/bisexual communityNonchalant and fatalistic attitudeCulture of silence and secrecyRegardless of the route of transmission, positive HIV status carries its own stigma.The HIV positive MSM is confronted with a combined social stigma of same sex preference and HIV infection, limiting open communication with MSM and even within the open homo/bisexual community.This gives rise to denial, fatalism and to a culture of silence and secrecy.

8Methods Exclusively qualitative research methodsFocus groups and in-depth interviewsBuilding mutual trust (investment of time, participating in social interactions)Maintaining confidentiality (fear of being seen and identified)The research is based on qualitative methods, combining focus groups and in-depth interviews.An anthropological approach based on conversations, personal involvement, and huge investment of time, participating in social interactions, was used to build mutual trust.Difficulty in getting groups together because of fears of being identified stresses the need for strict confidentiality.

9121 Participants (focus groups and Individuals interviews)Trinidad 25GrenadaSt. Lucia 22Barbados 8TobagoSt Kitts 15Antigua 11Dominica 6St Vincent 21In 9 islands, 121 participants in the study included openly gay men, closeted bisexuals, young gay and bisexual menThe use of two methods for collecting information was expected to minimize the bias created by the interviewer, being both part of the gay community and still an “outsider” coming from a different island/country.

10Results: Social DeterminantsCommunication and social interaction between classes and age groups is limitedLack of trust - within MSM and wider societySocial status mediates ability to copeSocial class dictates patterns of socialising and sexual mixingStronger sense of identity among younger and more educated MSMCommunication and social interaction between class, and between age sub-grouping is limited.The lack of trust within the group as well as between MSM and wider society are factors to take into consideration for public health interventions.Social class differences mediate ability to cope and live a normal life and dictate patterns of socializing and sexual mixing.Younger MSM and those who are perceived to be professionals have a stronger sense of identity. They need to be approached in ways that are different to those of older men and men from the lower social classes.

11Results: Sexual PatternsCommunities of interest on the basis of sexual preferences, sex practicesMultiple meanings of “sex”Negotiated safety of sexual intercoursePartner selection patterns are class relatedThe group is not homogenous. There are several communities, on the basis of sexual preferences, and sex practices. As such, most can be defined as communities of interest.The world “sex” has multiple meanings, from penetrative anal intercourse to erotic telephone conversations, including kissing, oral sex and masturbation. These distinctions should be clearly understood to ensure effective education and communication.Many MSM practice “negotiated safety”, engaging in unprotected sex with a main partner but, for outside partnership, using a condom or limiting relations to non-penetrative sex.Men from higher and middle class travel overseas to meet partners.Less well-off men have less opportunities to be selective in choosing a sex partner.

12Results: Sexual PatternsSize of MSM community larger than one would thinkIncreased MSM activity for economic need rather than sexual orientation or preferenceTrading sex, or sex with tourists for survivalStraight-identified men travel to other islands to meet male partnersThere is a perceived increase in the number of men having sex with other men, which seems to be driven by material and economic needs rather than sexual orientation or preference.Trading sex for money or material things as a matter of survival or upkeep is prevalent in some countries. In some others, sex with tourists is a common practice.In all countries there are men who live straight lifestyles in their home country and travel periodically to other countries to meet male partners.

13Results: MSM and HIV Safe sex known but hardly practisedCondoms reduce sexual pleasureCondom use mitigated by “knowledge” of partnerSkills for negotiating condom use at minimumLimited support towards HIV+ MSMLack of discretion in sharing information on sero- or health status of MSMMen are aware of the need for safe sex, but are not always able to practice it.Condoms are considered an obstacle for sexual pleasure and a bother in long-term relationships.The level of support that HIV positive individuals receive from the community is improving but still limited.Communities do not exercise discretion in sharing information about sero- or health status of MSM or other who have AIDS.

14Results: Access to Health CareAbsence of privacy in health care settings for testing and counsellingHeath care providers perceived as judgmental and unable to respect confidentialityPreference for private physicians and hospitalReluctance to seek care from heterosexual medical practitionersMen express reluctance to use health services for care or for counseling and testing.They perceive health care providers in the public sector as judgmental and unable to preserve confidentiality and privacy.Private physician and Hospital are preferred sources of testing.Some MSM express reluctance to seek care from heterosexual medical practitioners.The specific reasons for that were not explored.

15Conclusions First study of this kind in the CaribbeanCo-existence of heterosexual and homosexual epidemic in the CaribbeanCo-existence of underground homosexuality and visible heterosexual lifestyleCo-existence of high level of bisexuality among homosexuals and bisexual practices among heterosexualsThis is the first multi-country study on this subject in the regionEpidemiological data clearly indicate that HIV transmission in MSM co-exists with the heterosexual epidemic in the Caribbean.The co-existence of the two faces, one public, the other private, for MSM, presents a major challenge for AIDS prevention.

16Conclusions Lack of trust and communicationPoor dissemination of informationSocial denial: absence of MSM interventionsUnsafe sexual practicesHigh HIV prevalence in MSMImpacts the wider community through the bridge of bisexual practicesThe observed lack of trust and communication, contributes to the poor dissemination of information.The denial of the MSM aspect of HIV transmission results in the absence of interventions targeting MSM.This drives and maintains MSM in unsafe sexual practices resulting in a suspected high HIV prevalence in this community. This needs to be explored further.This impacts the wider community through the bisexual practices imposed by the pressure of society on the gay community.

17Conclusions: Urgent needsPolicy changes for improved access to public health and social servicesCommunity based interventions (HIV/AIDS awareness, sexuality, sexual health, safe sex)Operational research (gay issues, behaviour change, HIV prevalence)Legislative reforms to guarantee human rights protection regardless of sexual orientationPolicy changes are needed at the service delivery level to guarantee confidential and private health and social service to all and the respect of human rights.The need for community based interventions is challenged by the absence of structured communities. The small communities of interest are to be targeted.Additional research should explore more accurately the level of HIV prevalence in MSM, the socio-cultural determinants of sex practices, the effectiveness of educational interventions and assess health seeking behavior.The need for legislative reforms that guarantee the human rights of all members of society regardless of sexual orientation is in the public debate, but not yet on the political agenda.